OFFICE OF CHILD WELFARE PROGRAMS WELL BEING PROGRAM PLACEMENT

Office of Child Welfare Programs

Well Being Program

Placement Notification

To be completed by the provider and sent to this link: BRS Placement Support

Section A — Provider information

Provider name:

     

OR-Kids provider number:

     

Contact person:

     

Contact phone number:

     

Section B — Placement type

BRS placement:

Check one: Initial

Placement change within agency

(MUST COMPLETE SECTION D)

Non BRS placement:

Check one: Initial

Placement change within agency

(MUST COMPLETE SECTION D)

Section C — Placement information

Placement start date:

     

Child’s name:

     

Child’s date of birth:

     

Child’s OR-Kids ID:

     

Caseworker:

     

Facility

Name:

     

OR-Kids professional facility number:

     

Foster home

Name:

     

OR-Kids foster home number:

     

Physical address:

     

Phone:

     

Contract number:      

Rate per unit:      

Service category:      

Service type:      

Section D — Previous placement (ONLY complete if placement change within agency)

Previous placement start date:

     

Last night at previous placement:

     

Facility

Name:

     

OR-Kids professional facility number:

     

Foster home

Name:

     

OR-Kids foster home number:

     

Physical address:

     

Notes: